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💊 Hydrocortisone - Complete Clinical Guide

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1. What Is It?

• Glucocorticoid (anti-inflammatory / immunosuppressive) activity
• Mineralocorticoid (salt & water retaining) activity - more than other synthetic steroids

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2. Mechanism of Action (How It Works)

Step-by-step (simple version):

1. Hydrocortisone enters the cell and binds to the Glucocorticoid Receptor (GR) in the cytoplasm
2. The drug-receptor complex moves into the nucleus
3. In the nucleus it does two things:
   • Turns ON anti-inflammatory genes (e.g., lipocortin/annexin-1, IL-10)
   • Turns OFF pro-inflammatory genes by blocking transcription factors NF-kB and AP-1

Net effects:

Source: Goodman & Gilman's Pharmacology, Harrison's Internal Medicine 22E

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3. Indications (When to Use)

A. Replacement Therapy (primary use)

• Adrenal insufficiency (Addison's disease) - oral 15-25 mg/day in 2-3 divided doses
• Adrenal crisis (emergency) - IV bolus 100 mg
• Congenital adrenal hyperplasia (CAH)
• ACTH deficiency (secondary adrenal insufficiency)

B. Anti-inflammatory / Immunosuppressive

• Severe allergic reactions / anaphylaxis
• Asthma exacerbation
• Rheumatoid arthritis, gout (short-term)
• IBD (ulcerative colitis - rectal preparations available)
• Dermatitis, eczema (topical)

C. Perioperative / Stress Dosing

• Before major surgery in patients on long-term steroids: 100 mg IV at induction

D. Septic Shock

• Low-dose hydrocortisone (200 mg/day) in vasopressor-dependent septic shock

Source: Harrison's Internal Medicine, Rosen's Emergency Medicine, Barash's Clinical Anesthesia

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4. Contraindications

Absolute:

• Systemic fungal infections (spreads the infection)
• Hypersensitivity to hydrocortisone or any component
• Intrathecal route (spinal injection - absolutely forbidden for Solu-Cortef)
• Benzyl alcohol-containing preparations in neonates/premature infants (causes fatal gasping syndrome)

Relative (use with caution):

• Active TB or untreated infections
• Ocular herpes simplex (may worsen)
• Uncontrolled hypertension or heart failure
• Uncontrolled diabetes mellitus
• Active peptic ulcer disease
• Osteoporosis
• Myasthenia gravis
• Psychiatric disorders (can trigger psychosis)
• Immunocompromised patients (avoid live vaccines)
• Avoid abrupt withdrawal after long-term use (causes adrenal crisis)

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5. Dosing - Easy Summary Table

• Prednisolone: 0.2 mg = 1 mg hydrocortisone
• Prednisone: 0.25 mg = 1 mg hydrocortisone
• Dexamethasone: 0.025 mg = 1 mg hydrocortisone

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6. How to Give It - Administration Guide

IV Bolus (Direct Push):

• Inject over 30 seconds to 10 minutes (e.g., 100 mg over 30 sec in emergency)
• No dilution needed for IM or IV bolus - just reconstitute the powder with the supplied diluent

IV Infusion (Drip):

IM Injection:

• No dilution needed - inject the reconstituted solution directly into muscle (e.g., gluteus, deltoid)

Reconstitution (Act-O-Vial system):

1. Press down the plastic activator on top to mix powder + diluent
2. Swirl gently - do NOT shake
3. Remove protective cap, clean rubber stopper with alcohol
4. Insert needle and draw up required dose
5. Further dilute if making a drip

Source: Solu-Cortef dilution guide - GlobalRPH

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7. Side Effects (from prolonged use)

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8. Quick Safety Tips

• Never stop suddenly after >3 weeks of use - taper the dose to avoid adrenal crisis
• Monitor blood glucose (especially in diabetics)
• Monitor potassium (steroids cause hypokalemia)
• Give with food or antacids to protect the stomach (oral form)
• Use the lowest effective dose for the shortest duration
• Patients on long-term steroids need a steroid card and sick-day rules
• Pregnancy: Safe in low doses; may need 50% dose increase in the 3rd trimester

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🧪 Sodium Bicarbonate (NaHCO₃) - Complete Clinical Guide

Important note: "Sodium carbonate" (Na₂CO₃, washing soda) is an industrial chemical with no clinical use. The medical drug used in hospitals is Sodium Bicarbonate (NaHCO₃, baking soda). This guide covers sodium bicarbonate completely.

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1. What Is It?

• IV injection: 8.4% solution (1 mEq/mL) - most common in emergencies
• IV injection: 4.2% solution (0.5 mEq/mL) - preferred in neonates/children
• Oral tablets: for chronic conditions
• Isotonic infusion: prepared by diluting in D5W

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2. Mechanism of Action (How It Works)

The simple chemistry:

NaHCO₃  →  Na⁺  +  HCO₃⁻

HCO₃⁻  +  H⁺  →  H₂CO₃  →  H₂O  +  CO₂  (exhaled by lungs)

Net effects:

In TCA / sodium-channel blocker poisoning (special mechanism):

• The sodium load directly overwhelms blocked cardiac Na⁺ channels
• The alkalosis reduces TCA binding to cardiac channels
• Both effects together reverse QRS widening and arrhythmias

Sources: Rosen's Emergency Medicine | Washington Manual | Tintinalli's Emergency Medicine | Miller's Anesthesia 10e

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3. Indications

FDA-Approved:

Non-FDA (off-label but widely used):

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4. Contraindications

Absolute:

• Metabolic or respiratory alkalosis - will make it worse
• Hypocalcemia - bicarbonate lowers ionized calcium further (can cause tetany, seizures)
• Hypersensitivity to NaHCO₃ or any component
• Chloride loss from vomiting or NG suction (already alkalotic)
• Patients on hypochloremic-alkalosis-inducing diuretics (e.g., furosemide without replacement)

Relative (use with caution):

Drug Incompatibilities (Never mix in the same bag/line):

• Norepinephrine - incompatible (precipitates)
• Dobutamine - incompatible
• Calcium-containing solutions (e.g., Ringer's lactate) - causes precipitation
• Check all IV additives before mixing

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5. Dosing - Easy Reference Table

mEq needed = 0.3 × weight (kg) × base deficit Replace half over 4-8 hours; recheck ABG before giving more

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6. How to Give It + Dilution Guide

Available strengths:

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Route A: IV Bolus (Direct Push) - Emergency

• Use 8.4% solution undiluted
• Give 1 mEq/kg (= 1 mL/kg of 8.4%) over 1-3 minutes
• For TCA: push fast - 1-2 mEq/kg over 2-3 min, watch QRS narrow on monitor
• For cardiac arrest: 1 mEq/kg IV push

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Route B: IV Infusion (Drip) - Most Common Method

Take 3 ampoules of 8.4% NaHCO₃ (50 mL each = 150 mEq total) Add to 1 litre of D5W (dextrose 5% in water) Result: ~150 mmol/L isotonic bicarbonate solution

⚠️ Do NOT add to Normal Saline (0.9% NaCl) - makes the solution hypertonic with very high sodium content, risks hypernatraemia

• Typical: run over 4-8 hours
• For urinary alkalinization: run at 200-250 mL/hr, titrate to urine pH 7.5-8.0
• Monitor urine pH every 1-2 hours

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Route C: IM

• Not recommended - tissue necrosis risk due to hypertonicity

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7. Key Monitoring During Therapy

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8. Side Effects

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9. Quick Safety Rules (Must Remember)

1. Never stop suddenly in chronic alkalinization protocols - taper
2. Never mix with calcium in the same line or bag
3. Never give in alkalotic patients - always check ABG first
4. Use 4.2% in children under 2 - not 8.4%
5. Do not give routinely in cardiac arrest - only for specific causes (hyperK, TCA, cocaine)
6. Increase ventilation when giving NaHCO₃ - CO₂ produced must be blown off
7. Target pH 7.10-7.20, not full correction - overcorrection is dangerous
8. Use a separate IV line - incompatible with many drugs

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Sodium Bicarbonate (NaHCO₃) - Super Easy Guide

The medical name is Sodium Bicarbonate (not sodium carbonate). Same thing as baking soda, but used as medicine!

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💡 What Does It Do? (Mechanism)

Acid (H⁺)  +  Bicarbonate (HCO₃⁻)  →  Water + CO₂ (you breathe out CO₂)

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✅ When to Give It (Indications)

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❌ When NOT to Give It (Contraindications)

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💉 Dose - Easy Numbers

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🧪 How to Prepare & Give It

💊 What comes in the vial:

• 8.4% = 1 mEq per 1 mL → used in adults (hypertonic, strong)
• 4.2% = 0.5 mEq per 1 mL → used in children

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🚨 Emergency Bolus (Fast push):

1. Draw up 8.4% NaHCO₃
2. Give 1 mEq/kg = 1 mL/kg of 8.4%
3. Push over 1-3 minutes IV
4. No dilution needed for emergency bolus

Example: 70 kg patient → give 70 mL of 8.4% over 2-3 min

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🔽 Drip (Infusion):

3 amps (50 mL each) of 8.4% NaHCO₃ + 1 litre of D5W = Isotonic bicarbonate drip ✅

⚠️ Never mix with Normal Saline (NS) - too much sodium ⚠️ Never mix with calcium - will precipitate (go cloudy) ⚠️ Never mix with norepinephrine or dobutamine - incompatible

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👁️ What to Watch (Monitoring)

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⚠️ Side Effects to Know

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🧠 5 Things to Always Remember

1. 🩸 Check ABG before giving - never give blind if patient may already be alkalotic
2. 🧒 Use 4.2% in children - never give 8.4% undiluted to babies
3. 🫁 Increase breathing rate when giving - body makes CO₂ that must be blown off
4. 🚫 Never mix with calcium or norepinephrine in same line
5. 🎯 Target pH 7.1-7.2, not full correction - stop before normal

🧪 Sodium Bicarbonate - Full Detail in Easy Language

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🔬 PART 1: MECHANISM (How It Works)

First, understand normal blood pH:

• Normal blood pH = 7.35 - 7.45
• Below 7.35 = Acidosis (too acidic = dangerous)
• Above 7.45 = Alkalosis (too alkaline = also dangerous)

What happens in acidosis?

• Heart muscle becomes weak
• Blood vessels dilate (BP drops)
• Body stops responding to adrenaline
• Potassium rises (deadly heart rhythms)
• Patient can die

How does NaHCO₃ fix this?

Simple equation:
H⁺  (acid)  +  HCO₃⁻  →  H₂O  +  CO₂ (exhaled)

3 Ways it works depending on the situation:

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✅ PART 2: INDICATIONS (When to Use)

A. Emergency / Life-threatening situations:

• Blood pH drops below 7.10
• Causes: kidney failure, sepsis, shock, DKA
• Give NaHCO₃ to raise pH back above 7.10
• Goal: pH 7.1-7.2 (do NOT fully correct - that's dangerous too)

• K⁺ > 6.5 mEq/L with ECG changes
• NaHCO₃ shifts K⁺ into cells within 15-30 minutes
• Temporary fix only - still need definitive treatment (dialysis, Kayexalate)

• Drugs like amitriptyline, imipramine block heart Na⁺ channels
• Signs: wide QRS > 100ms, low BP, seizures, arrhythmias
• NaHCO₃ is the #1 treatment here
• Give bolus fast - watch QRS narrow on the monitor

• Cardiac arrest from hyperkalemia → YES give it
• Cardiac arrest from TCA overdose → YES give it
• Routine cardiac arrest → NO, not recommended (can worsen outcomes)

• Makes urine alkaline → aspirin gets trapped in urine → excreted faster
• Target urine pH = 7.5 - 8.0
• Keep running infusion until salicylate level drops

• Muscle breakdown releases myoglobin
• Myoglobin clogs and damages kidneys
• Alkaline urine prevents myoglobin from crystallizing in kidney tubules
• Give with IV fluids to flush the kidneys

B. Non-emergency situations:

• Kidneys can't make enough bicarbonate
• Give oral NaHCO₃ tablets long-term
• Target: bicarbonate level > 22 mEq/L

• Kidney tubules leak bicarbonate
• Replace with oral NaHCO₃

• Methotrexate overdose
• Ethylene glycol (antifreeze) poisoning
• Make urine alkaline to speed up drug removal

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❌ PART 3: CONTRAINDICATIONS (When NOT to Give)

Absolute (Never give):

Relative (Use very carefully):

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💉 PART 4: DOSES (Easy Numbers)

Available strengths - know these:

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Dose by situation:

1 mEq/kg IV push over 1-3 minutes Using 8.4%: give 1 mL/kg Example: 60 kg patient = 60 mL of 8.4% pushed over 2 min

First bolus: 1-2 mEq/kg fast push Repeat boluses every few minutes until QRS < 100ms Then start infusion (150 mEq in 1L D5W) at 250 mL/hr Stop when QRS narrows and BP recovers

2-5 mEq/kg in drip form over 4-8 hours Check ABG after each correction

150 mEq in 1 litre D5W running continuously Adjust rate to keep urine pH = 7.5-8.0

mEq needed = 0.3 × body weight (kg) × base deficit Replace only half in the first 4 hours Recheck ABG and recalculate

325 mg to 2000 mg (1-6 tablets) 2-3 times daily Adjust based on serum bicarbonate level

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🧪 PART 5: HOW TO PREPARE & GIVE IT

Step-by-step: Making a drip

Standard Isotonic Drip (most used):

Take 3 × 50 mL ampoules of 8.4% NaHCO₃
(= 150 mEq total)

Add into 1 litre bag of D5W

Mix gently

= Isotonic sodium bicarbonate solution (150 mEq/L)

Small volume urgent drip:

Take 1 ampoule 8.4% (50 mEq)
Add into 500 mL D5W
= 100 mEq/L solution

Never use Normal Saline (NS) as diluent:

• 8.4% NaHCO₃ + NS = extremely high sodium solution
• Causes severe hypernatraemia

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How fast to run it:

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⚠️ Incompatibilities - Things you must NEVER mix:

Rule: Always give through its own dedicated IV line or flush well before/after

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👁️ PART 6: MONITORING

What to check and when:

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⚠️ PART 7: SIDE EFFECTS

From too much NaHCO₃:

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🧠 PART 8: GOLDEN RULES - EASY TO REMEMBER

✅ CHECK ABG BEFORE giving - is patient acidotic or alkalotic?
✅ Target pH 7.10 to 7.20 only - don't over-correct
✅ Use 4.2% in children and babies - never 8.4% undiluted
✅ Dilute in D5W only - never normal saline
✅ Give on its own IV line - keep away from calcium & noradrenaline
✅ Breathe more CO₂ out - increase ventilator rate if intubated
✅ Watch potassium - it will drop with bicarbonate therapy
✅ Watch calcium - it will drop with bicarbonate therapy
❌ Never give in alkalosis
❌ Never give in low calcium
❌ Never give routine cardiac arrest (only hyperK / TCA)

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📊 QUICK SUMMARY CARD